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Volume 25, Number 6—June 2019

Assessment of Economic Burden of Concurrent Measles and Rubella Outbreaks, Romania, 2011–2012

Joseph Njau1, Denisa Janta, Aurora Stanescu, Sarah S. Pallas, Adriana Pistol, Nino Khetsuriani2, Susan Reef, Daniel Ciurea, Cassandra Butu, Aaron S. Wallace, and Laura ZimmermanComments to Author 
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (J. Njau, S.L. Pallas, S. Reef, A.S. Wallace, L. Zimmerman); National Public Health Institute, Bucharest, Romania (D. Janta, A. Stanescu, A. Pistol); Centers for Disease Control and Prevention, Tbilisi, Georgia (N. Khetsuriani); Center for Health Policies and Services, Bucharest (D. Ciurea); World Health Organization Country Office, Bucharest (C. Butu)

Main Article

Table 1

Definitions and data sources used for cost components during assessment of economic burden of concurrent measles and rubella outbreaks, Romania, 2011–2012*

Cost component Definition Data sources
Healthcare provider
All reimbursements for diagnostic testing for measles and rubella, inpatient and outpatient care, emergency treatment, case management
Reimbursement data from National Health Insurance House (CNAS) covering all registered government healthcare providers using the Romanian national clinical diagnosis codes associated with measles and rubella diagnoses, outpatient and inpatient care, and vaccinations (Appendix Table), as submitted by healthcare providers
National outbreak response
Enhanced surveillance, laboratory diagnosis and confirmation, field activities such as case investigations, and outbreak response immunization, including actual expenses incurred for personnel, laboratory supplies, and vaccine doses provided to contacts of cases and to high-risk communities
Interviews with key personnel, including the Director of the National Institute for Public Health, Romanian MOH; the Team Leads for Measles and Rubella, National Center for Surveillance and Control of Communicable Diseases, MOH; a measles and rubella epidemiologist from the District Public Health Authorities, MOH; the Director of the reimbursement department and an analyst at the National Health Insurance House (CNAS); and the Head of Country Office and a public health officer at the World Health Organization country office in Romania
Direct medical and nonmedical household
Medical costs (e.g., consultation fees, laboratory tests and medications) and nonmedical costs (e.g., transport, food and lodging) paid out-of-pocket by cases and caregivers
Household survey of 428 recent case-patients (within last 18 months) by using structured telephone interviews
Indirect household
Workdays lost by cases and caregivers because of measles or rubella infections
Household survey of 428 recent case-patients (within last 18 months) by using structured telephone interviews; 2012 Romanian national minimum wage of 700 Lei/month was used as proxy to quantify the value of lost workdays by patients and caretakers >18 y of age (8).
CRS cases healthcare provider
All diagnostic services, inpatient and outpatient care reimbursements related to CRS diagnostic codes for identified CRS cases during timeframe
Reimbursement data from National Health Insurance House (CNAS) covering all registered government healthcare providers for the 27 CRS cases identified from the time of the outbreak up to the date of data collection; reimbursement data were obtained for 18 (11 surviving and 7 who had died) of the 27 case-patients
CRS cases lifetime discounted indirect Workdays lost by CRS cases over assumed lifetime productive working years (18–63 y) 2012 Romanian national minimum wage of 700 Lei/month was used as a proxy to quantify the value of lost workdays by patients >18 y of age (8)

*CNAS, Casa Nationala de Asigurari de Sanatate; CRS, congenital rubella syndrome; MOH, Ministry of Health.

Main Article

  1. Ortega-Sanchez  IR, Vijayaraghavan  M, Barskey  AE, Wallace  GS. The economic burden of sixteen measles outbreaks on United States public health departments in 2011. Vaccine. 2014;32:13117. DOIPubMedGoogle Scholar
  2. Wallace  AS, Masresha  BG, Grant  G, Goodson  JL, Birhane  H, Abraham  M, et al. Evaluation of economic costs of a measles outbreak and outbreak response activities in Keffa Zone, Ethiopia. Vaccine. 2014;32:450514. DOIPubMedGoogle Scholar
  3. Lanzieri  TM, Segatto  TC, Siqueira  MM, de Oliviera Santos  EC, Jin  L, Prevots  DR. Burden of congenital rubella syndrome after a community-wide rubella outbreak, Rio Branco, Acre, Brazil, 2000 to 2001. Pediatr Infect Dis J. 2003;22:3239. DOIPubMedGoogle Scholar
  4. Njeru  I, Onyango  D, Ajack  Y, Kiptoo  E. Rubella outbreak in a Rural Kenyan District, 2014: documenting the need for routine rubella immunization in Kenya. BMC Infect Dis. 2015;15:245. DOIPubMedGoogle Scholar
  5. Hahné  S, Macey  J, van Binnendijk  R, Kohl  R, Dolman  S, van der Veen  Y, et al. Rubella outbreak in the Netherlands, 2004-2005: high burden of congenital infection and spread to Canada. Pediatr Infect Dis J. 2009;28:795800. DOIPubMedGoogle Scholar
  6. Curtale  F, Perrelli  F, Mantovani  J, Ciofi degli Atti  M, Filia  A, Nicoletti  L, et al. Description of two measles outbreaks in the Lazio Region, Italy (2006-2007). Importance of pockets of low vaccine coverage in sustaining the infection. BMC Infect Dis. 2010;10:62. DOIPubMedGoogle Scholar
  7. National Public Health Institute. National Center for Surveillance and Control of Communicable Diseases. The 2011/2012 measles outbreak in Romania. Bucharest (Romania): the Institute; 2013.
  8. Vladescu  C, Scintee  G, Olsavszky  V. Romania health system review. In: Mladovsky SA, editor. Health systems in transition. London: The European Observatory on Health Systems and Policies; 2008 [cited 2019 Mar 17].
  9. Johannesson  M. The willingness to pay for health changes, the human-capital approach and the external costs. Health Policy. 1996;36:23144. DOIPubMedGoogle Scholar
  10. National Bank of Romania (NBR). Exchange rates: monthly, quarterly and annual averages. Bucharest (Romania): NBR; 2013.
  11. Institut National de Statistica. Consumer price index. December 2013 edition. Bucharest (Romania); The Institut; 2016.
  12. Xu  K, Evans  DB, Kawabata  K, Zeramdini  R, Klavus  J, Murray  CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362:1117. DOIPubMedGoogle Scholar
  13. Xu  K, Evans  DB, Carrin  G, Aguilar-Rivera  AM, Musgrove  P, Evans  T. Protecting households from catastrophic health spending. Health Aff (Millwood). 2007;26:97283. DOIPubMedGoogle Scholar
  14. Raban  MZ, Dandona  R, Dandona  L. Variations in catastrophic health expenditure estimates from household surveys in India. Bull World Health Organ. 2013;91:72635. DOIPubMedGoogle Scholar
  15. Tambor  M, Pavlova  M, Rechel  B, Golinowska  S, Sowada  C, Groot  W. The inability to pay for health services in Central and Eastern Europe: evidence from six countries. Eur J Public Health. 2014;24:37885. DOIPubMedGoogle Scholar
  16. Stepurko  T, Pavlova  M, Gryga  I, Groot  W. To pay or not to pay? A multicountry study on informal payments for health-care services and consumers’ perceptions. Health Expect. 2014.PubMedGoogle Scholar
  17. Atanasova  E, Pavlova  M, Moutafova  E, Rechel  B, Groot  W. Out-of-pocket payments for health care services in Bulgaria: financial burden and barrier to access. Eur J Public Health. 2013;23:91622. DOIPubMedGoogle Scholar
  18. The World Bank. Health expenditure per capita (current US$). World development indicators. Washington: World Bank and World Health Organization; 2013.
  19. Acharya  A, Diaz-Ortega  JL, Tambini  G, de Quadros  C, Arita  I. Cost-effectiveness of measles elimination in Latin America and the Caribbean: a prospective analysis. Vaccine. 2002;20:333241. DOIPubMedGoogle Scholar
  20. Carabin  H, Edmunds  WJ, Kou  U, van den Hof  S, Nguyen  VH. The average cost of measles cases and adverse events following vaccination in industrialised countries. BMC Public Health. 2002;2:22. DOIPubMedGoogle Scholar
  21. Hinman  AR, Irons  B, Lewis  M, Kandola  K. Economic analyses of rubella and rubella vaccines: a global review. Bull World Health Organ. 2002;80:26470.PubMedGoogle Scholar
  22. Lanzieri  TM, Parise  MS, Siqueira  MM, Fortaleza  BM, Segatto  TC, Prevots  DR. Incidence, clinical features and estimated costs of congenital rubella syndrome after a large rubella outbreak in Recife, Brazil, 1999-2000. Pediatr Infect Dis J. 2004;23:111622.PubMedGoogle Scholar
  23. Al-Awaidy  S, Griffiths  UK, Nwar  HM, Bawikar  S, Al-Aisiri  MS, Khandekar  R, et al. Costs of congenital rubella syndrome (CRS) in Oman: evidence based on long-term follow-up of 43 children. Vaccine. 2006;24:643745. DOIPubMedGoogle Scholar
  24. Kurbanov  B, Musabaev  E, Latipov  R. The economic burden of congenital rubella syndrome and vaccination in Tashkent City, Uzbekistan. EpiNorth. 2012;13:1824.

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1Current affiliation: JoDon Consulting Group LLC, Atlanta, Georgia, USA.

2Current affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Page created: May 20, 2019
Page updated: May 20, 2019
Page reviewed: May 20, 2019
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